August 09, 2019

Pramila Jayapal

Rep. Pramila Jayapal, co-sponsor of the House Medicare for All Act, makes the case for a universal government-run health insurance program. She explains why she supports eliminating private insurance and what that would mean for the 150 million+ people with employer-based coverage. She also talks about the cost of Medicare for All and whether wait times for doctors’ visits would change.

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She’s not running for president, but you might say her Medicare for All bill is.
This week on ‘Firing Line’…
Is this a bold and ambitious plan?
Damn straight it is.

In her second term in the House of Representatives, Congresswoman Pramila Jayapal has introduced Medicare for All legislation that would dramatically overhaul healthcare in America.

If we can end slavery, if we can give women the right to vote, if we can send a man to the Moon, then, God, we can do universal healthcare for every American!
[ Cheers and applause ]
In conjunction with Bernie Sanders’ Senate version of the bill…
Our job is to lead the world on healthcare, not to be woefully behind every other major country.

…everyone would be covered and everyone would be affected.
No more copays, no more premiums, and no more private insurance.
The idea is catching fire on the campaign trail.

We need to have Medicare for All.

Medicare for All.

I support Medicare for All.

Medicare for All.

He should put billions of dollars toward Medicare for All.

But are some candidates rallying behind the catchy slogan without really embracing the policy?

Who here would abolish their private health insurance in favor of a government-run plan?
Just a show of hands to start out with.
[ Applause ]
What does Representative Pramila Jayapal say now?

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Representative Pramila Jayapal, welcome to ‘Firing Line.’

Thank you, Margaret.
I’m so happy to be here.

It’s a delight to have you here.
You are now in your second term in the House of Representatives, representing Washington’s 7th district.


And I’m delighted you’re here today so that we can talk about one of your key issues, which is Medicare for All.
And it is also an idea that almost every single Democratic candidate is rallying around and claiming to be part of, although to varying degrees.

Yes, correct.
That is a very accurate description.

So, I want to talk about that, but, first, in an issue that is fraught with distinctions and differences and entrenched interests, it seems to me that the first point of agreement and maybe the only point of agreement is that the status quo to almost everyone involved is insufficient.

That’s absolutely right.
I mean, I think if you look at our healthcare system in the country today, you have 70 million people who are either uninsured or underinsured.
And then you have tens of millions more who simply cannot afford healthcare, people who are using GoFundMe as their insurance plan, and it is a crisis in this country, and I think it’s one that every single working family across the country is dealing with in some way, shape, or form.

Do you sense that, as you begin to look for reforms, especially on the Democratic side but across the universe of stakeholders in the healthcare environment, that most people believe that there is a way to reform the healthcare system and are coming to the table in good faith?

I do think that.
I mean, it started with the Affordable Care Act.
I think the Affordable Care Act covered tens of millions of more Americans across the country and actually made it so that Americans started to think, ‘Wait a second — healthcare is a right and not a privilege.’

Since you mentioned the Affordable Care Act, let me just play a clip of President Obama talking about the Affordable Care Act, ’cause it is shocking to think that it was just 10 years that Democrats were pushing a major reform to healthcare that is quite different than Medicare for All.
Let’s take a listen.

Today, after over a year of debate… today… after all the votes have been tallied… health-insurance reform becomes law in the United States of America.
[ Cheers and applause ]
So, that was only 10 years ago.
But the Affordable Care Act has really fallen out of popularity in parts of the Democratic Party.
Is that fair?

No, I think it’s not that it fell out of popularity.
I think it is that the Affordable Care Act was the first step.
But the problem is it didn’t actually reform the whole system, so it expanded healthcare for tens of millions of Americans but did not and was not trying to be, I would say, in fairness, a system that covered everybody.

Do you believe that the system actually can be reformed, or do you believe it has to fundamentally be changed?

To me, those two things are the same.
You know, it can be reformed, and it has to fundamentally be changed.
We pay almost double the healthcare costs of any industrialized country, but, in fact, the United States today has the worst maternal mortality rates, the worst infant mortality rates, the worst rates of life expectancy of any peer country in the world.

To be fair, there are a lot of reasons life expectancy is low, right?
Life expectancy is low because we have a lot of shootings, because we have a lot of car crashes, because we have an obesity crisis.
Sometimes that’s not due directly to the healthcare.

Most of it is, though.
Most of the studies show that the United States is — You’re absolutely right.
There’s lots of reasons for low life expectancy.
But when you think about infant mortality and maternal mortality, those are some of the biggest reasons that you have low life expectancy.
You have issues with diabetes.
You have all these other crises that people are facing, and so it’s pretty clear, when you look at the statistics — and I did public health for 10 years before doing all of this work — that the United States does not have a healthcare system that provides healthcare for everybody and doesn’t do it at the points when it should.
I mean, this isn’t a new idea.
It’s not a radical idea.
It is actually what Teddy Roosevelt, Harry Truman, Lyndon Johnson, all of them, actually tried to get to that place, but at the time, the systems that were put in place, whether it was Medicare or Medicaid — those weren’t creating the same amount of profit that they are today.

I mean, Medicare for All, again, wasn’t a catchphrase.
It wasn’t something everybody was running on until rather recently.
So, when was the first time you heard ‘Medicare for All’?
I would say Bernie really popularized ‘Medicare for All’ back in 2015.
He used to talk about it all the time.
It was part of his campaign.

Let’s look at a clip.

We are gonna say loudly and clearly that every person in this country will have healthcare.
We’re gonna do it in a cost-effective way, and that is a Medicare for All, single-payer program.

Okay. So, there you go.
That was back in 2015, just as you said, but now every single 2020 candidate has something to say about Medicare for All.
Let’s take a look.

Healthcare is a right.
I think the best way to get there is Medicare for All.

I do believe Medicare for All is the right solution for healthcare.

I strongly believe that we need to have Medicare for All.

And we figure out how to do Medicare for All in a way that makes sure that we’re gonna get 100% coverage.

Alright. So, just for the benefit of the audience, here everybody’s talking about Medicare for All.
Most people know what Medicare is.
Can you just explain in plain terms the difference — Medicare versus Medicare for All?

Yeah. Absolutely.
So, Medicare for All is an expanded and improved Medicare system.

Medicare, the system which provides healthcare to those 65 and older.

Exactly — seniors 65 and older…
And others with disabilities.

…but is somewhat limited.
People love their Medicare, but they say it doesn’t cover enough.
So, what do you get from Medicare for All?
You get comprehensive care.
You get medical, dental, vision, mental health, reproductive health, long-term supports and services — everything that you need to be healthy as an individual.
No copays, no private insurance premiums, no deductibles.
The only thing that changes in Medicare for All is who provides the insurance, if you will, right?
So, the government would provide a guaranteed insurance plan, but you would use the same doctors and hospitals.

So, what if a doctor doesn’t want to be in the system, a Medicare for All system?

Well, most doctors will want to be in it because when it’s covering everybody, that is the main marketplace.

So they won’t have a choice.

Probably not.
I mean, this would be — Doctors would be a part of it.

So, in Medicare for All, which is actually a new system…
It’s an expanded and improved Medicare system, because we’re adding people to Medicare all the time.
There’s no reason to not expand it.

But this would put in who?

This would be everybody, so everybody would be covered.
‘Everybody in and nobody out’ is the phrase we use.

Okay. So, would it mean the elimination of private insurance?

So, what it would mean is that, just like Medicare, you wouldn’t be able to offer a private insurance plan that covers the same services and benefits that are covered under this plan.
But if private insurance wanted to exist and cover something that isn’t covered by this plan, they would be free to do that.
That is how Medicare Advantage came up, because —
No, but I thought you said everything will be covered.

Not everything, but comprehensive care.

What kind of things wouldn’t be covered?

Well, you know, cosmetic surgery probably wouldn’t be covered.
There would be certain — you know, certain other things.
But it would be a limited set of things.

So, private insurance wouldn’t be able to compete with the offerings of the government.

Exactly, which is the case now with Medicare.
It’s just that Medicare is a narrower set of benefits right now.
Medicare for All would be an expanded set of benefits.
In the end, it is cheaper for everybody to actually go to see the doctor when you first get sick versus to wait until the very end, and that’s separate from the moral imperative to actually provide healthcare for everyone.

So, as you know, there are about approximations of between 150 million to 180 million people who are currently on employer-based private insurance.


Would they lose their insurance?

Well, they wouldn’t lose —
By the way, 71% or so are happy with that insurance.

Right, absolutely, and they would stay —
What happens to them?

So, they would be covered by the guaranteed insurance plan that the government would be providing.
All it is is we’re cutting out the insurance companies that are providing the insurance, but you get to see the same doctors and hospitals.

But here’s the question I have, because private insurance ultimately, as you know, in the healthcare system, it’s actually paid for through reimbursements, and Medicare is billed at a lower rate, and private insurance is billed at a higher rate.


And if private insurance no longer exists…

…and is not able to overpay for services…

…will there be as much money in the system to provide as many services to the population of Americans?

It’s such a great question.
So, what we would do in our plan is we would actually have a rate, reimbursement rate, that is somewhere between Medicare and what’s called an all-payer rate.
So, the rate would at least be as much as Medicare and perhaps more.
Are there some people who are gonna make less money?
Well, certainly, the insurance C.E.O.s will make less money.
Some of the specialty doctors at the very top of the scale may make a little bit less, but the majority of doctors — and we have incredible support from the physicians because they are tired of spending 30% of their time on administrative costs, trying to convince insurance companies that they actually should provide the payment for treatment that the doctors know their patients need.

In the first round of presidential debates…

…over two nights of debates, only four candidates have raised their hand for your version of Medicare for All, the one that would eliminate private insurance and do what your bill outlines.


So, this question about whether you keep private insurance or not is a debate in the Democratic Party.
Let’s roll the clip of de Blasio and O’Rourke.

Would you replace private insurance?

No. I think the choice is fundamental to our ability to get everybody cared for.

Private insurance is not working for tens of millions of Americans when you talk about the copays, the deductibles, the premiums, the out-of-pocket expenses.
It’s not working.
How can you defend a system that’s not working?

So, for those for whom it’s not working, they can choose Medicare.

Congressman, you got to start by acknowledging the system is not working for people.

They’re able to keep ’em.

Why are you defending private insurance?

Alright. And then what happened after that is you had Representative Delaney say the problem here is that we’re throwing the baby out with the bath water.


Right? That if you keep private insurance, if people like it, let them keep it.
And then why not provide for those who don’t have the ability or the opportunity to buy in to private insurance a Medicare for All?

The average family who’s buying insurance on the marketplace or is covered by employer insurance is paying anywhere from $18,000 to $20,000 a year in those costs.
So what’s happening is private insurance companies are raising premiums even on employers, so employers either have to cover that cost on their own or they have to push it down to their employees.
Employer healthcare — sure, a lot of people like it, but there are a lot of people that are absorbing enormous amounts of costs, and it’s not just employees.
It’s also employers, which is why we have this great coalition of small businesses, medium-sized businesses, and even now larger businesses who are saying, ‘We cannot be competitive.’
Warren Buffett called healthcare — I think he called it ‘the tapeworm of economic competitiveness,’ if I have that right.
Basically, what he’s saying is it is killing our balance sheet.

I mean, this is certainly one of the areas where all of us agree.
It is too expensive, and there are ways to reform it.
I think there are different competing ideas about how to reform it.
I mean, there are models within Medicare itself that have proven successful at bending the cost curve.
If you look at Medicare Part D, for example, it has kept prescription-drug prices lower than it would have otherwise.
The same is true for Medicare Advantage.

But here’s the thing about Medicare Advantage.
It’s an enormously expensive program.
People like it because wouldn’t you want to have vision and, you know, hearing aids and dental?
That is really important as you become older.
I mean, it’s important anytime, but certainly when you become older, but you’re paying all these multiple plans.
People are tired of having to pay for five different…
But that is what’s kept the cost from growing, because there’s competition between these multiple plans, isn’t it?

If you have a large enough system, you can negotiate a far lower rate.
Americans should not be paying double the cost of prescription drugs than they do in Canada.
I mean, this is ridiculous.
And the insurance companies can find another way to make money.
God bless ’em.
Find the other way.
But don’t make it off of the profits of people who desperately need healthcare so that they can exist and live and have a decent life.

The only thing I feel like I can’t let you get away with is just saying that — You know, the profit motive has generated benefits to the system, as well, in terms of innovation…
What innovation?

…and in terms of all of the innovation in medical — I mean, think about how, in the United States, we are leading in immunotherapies and in gene therapies.
Immunotherapy — the thing that has kept Jimmy Carter alive.

But that’s resear–
And that is with the profits from pharmaceutical companies.

But — Okay.
Most of those technologies were actually funded by government research, and there’s lots of — there is lots —
Over $70 billion a year into research and development — that is a huge amount of money.
And if the price is drugs…

…then, I mean, how — You hear the saying that today’s medicines pay for tomorrow’s research.

Well, we should talk about pharmaceutical drugs and research as a whole separate topic.

I know.
We need another 30 minutes.

But I will tell you that a lot — and I’ve spent a lot of time looking at this — There are lots of research and innovation opportunities, including the federal government continuing to provide some of that key funding, even more, perhaps, for pharmaceutical drugs, but that’s a different — That has nothing to do with Medicare for All.
Healthcare is a basic human right.
That is what I fundamentally believe.
And these basic human rights should be provided by the government.

I’d like to talk about whether it’s a basic human right.
I mean… when one thinks about rights, when I think about fundamental rights, I think about the Bill of Rights.
I think about the fact that we have the freedom of speech.
We have the freedom to practice our religion.
We have the freedom to peaceably assemble.
These are all fundamental freedoms that we’ve agreed in this country exist for us to protect us from government overreach.
When I think about healthcare, I think it’s a service that somebody purchases and is provided.
How is a service that is provided to somebody a fundamental right in the way that freedom of speech is a fundamental right?

Right. If you get sick, you have no access to any of the other rights.
This is a fundamental piece of who we are as human beings.
You have to be able to access healthcare in a way that is affordable and doesn’t drive you into bankruptcy.

So, is that a responsibility of a civilized postindustrial country, or is it a fundamental right?
And I, to me, I mean, I think I would be happy to pay more so that people don’t fall through the cracks, so that they have basic healthcare, and I think of that as a responsibility of a civilized society that is caring and compassionate and postindustrial…
That’s because you’re — you’re —
…but not a fundamental right, because when you call it a fundamental right, doesn’t that then imply that there’s a moral responsibility and imperative for the government to pay?

If you want to call it a responsibility and I want to call it a right, the end goal is the same, and we could argue about that, and I do believe it’s a right, but I also believe that it’s fine if you think it’s a responsibility.
The reality is neither one of us is getting our needs met with this system.
70 million people in the richest country in the world cannot access healthcare.

Let’s talk about the cost.
The major factor here, the elephant in the room that we haven’t discussed yet, is cost.


Cost to the system, cost to the economy overall, and cost to the individual.


The cost overall has been estimated roughly by right-wing think tanks and left-wing think tanks roughly at $32 trillion…
Over 10 years.

…over 10 years.

So, $3.2 trillion a year.
And that’s the Koch brothers’ estimate, but let’s take that as the estimate.

Sure. I mean —
I’m just going to accept that estimate — $32 trillion over 10 years.
2/3 of the cost of our current system is already paid for by the federal government.
Why? Because it’s Medicare, Medicaid, and public subsidies.
Then you just need to come up with a little less than a trillion dollars in funds that the federal government is not already paying.
The employer industry is paying about $700 billion a year in costs, but they’re paying it to private insurance companies, not to the government.
So many of the businesses I’ve talked to have said, ‘God, please, take health insurance off of my books.
I will pay even a portion of that to the government to cover that and to cover the cost of health insurance’ — by the way, health insurance that people could have no matter what job they had.
A big part of that would go to the federal government, and then you got to come up with, you know, depending on how you look at the costs, anywhere from $300 to $400 billion a year, which would be a cinch to do with a financial-transaction tax on the wealthiest, a tiny capital-gains tax.
There are all kinds of ways to come up with that money very easily.

So, explain to me — One analysis said that you could double — doubling all currently projected federal, individual, and corporate income-tax collections would actually be insufficient to finance the added federal cost of the plan.

I don’t know what study that is, but a lot of —
It’s the Cato Institute, say.

Well, I mean —
It’s a Libertarian think think, right.

But, also, they’re not looking at the current cost, so they’re saying —
They’re saying all the federal costs.

Right. I mean, they’re saying that this is a new cost, and what I want to make sure people understand is we are already paying this money.
The federal government is already paying 2/3 of the healthcare costs in this country.
It could cut administrative waste out of the system immediately and save a tremendous amount of money on overall healthcare costs.

I have heard that there is a fallacy with this idea that the government would be more efficient, that, somehow, all of this would be administered in a very streamlined way, because it is administered through different departments, and so it is hard to get a cost of how this administration would work.
It would be administered through HHS.
It would be administered through the IRS.
It would be administered through so many different agencies that it isn’t just one.

Medicare is the closest example to that.
I mean, you can look at the Medicare system, which the government administers today, and the cost of just pure Medicare is 2%. The idea that government can’t do this efficiently is just not borne out by experience.

And so then, ultimately, you would raise taxes in some way on the wealthy or on corporations or on individuals to pay for that delta?

For the final delta, yeah, you could make any number of, you know, small tax increases on the very wealthiest.
A financial-transactions tax would bring you way more money than you need.
But, most importantly, what you get for it is the average family would probably pay 14% less in total costs because the costs of the healthcare system out of pocket are getting absolutely unaffordable, and they’re breaking American families.

This program was hosted originally by William F. Buckley Jr.
You won’t be surprised that in 1974, he debated specifically this issue.


He didn’t call it Medicare for All, but it was a debate with Max Fine, a member of JFK’s Medicare Tax Force…

…about government-run national healthcare insurance program.
Let’s take a look.


Well, I think the quality of care in England is very good.

And the fact that they like it is just immaterial.

[ Laughs ] I love it!

What about the question of wait times?

I think that England is a different system, right?
England is a system where the government actually controls the hospitals and the doctors.
It is a National Health Service.
Canada is not that.
Germany is not that.
There are a lot of places that have a system where the insurance is provided by the government but the actual system is privately administered.

And I’ve heard you say that the system of Medicare for All would be most like the Canadian system.
Is that accurate?

Yes. I think that’s probably the most similar.

Well, it’s true, though, in Canada that there are pretty extraordinary wait times for many, many services.

Right. In general, if you look at Canada, Germany — Germany’s slightly different to some of the other European countries — you find that people don’t have enormous wait times that are, you know —
So, you’re saying there wouldn’t be wait times if we switch over to a Medicare for All system?

There is a sense in the United States that, you know, you have to go and you have to get something immediately, right?
Half the time you go and you find out that there’s something going on, and somebody says, ‘Okay, you have to go get an MRI today.’
Might you have to wait a day to get your MRI?
The reality is today people are not getting care!
You want to talk about wait times?
Let’s talk about the fact that 70 million people don’t get care across a country.
That’s a pretty significant wait time for everybody that can never access healthcare in this country.

Except that there are people that don’t have the wait times, and so the question is how do you —
Correct. The wealthiest people today in this country —
Not even — The 150 million people that have private employer-provided health insurance — they have very few wait times.
I mean, it really is not a feature in our system.

The reality is the vast majority of people who get healthcare, you know, of the highest quality whenever they want it, as much of it as they want, are the wealthiest, and I think we have to put ourselves in the place of reimagining a country where everyone can get the care that they need.

Even if it means waiting a little bit longer?

You might have to wait a little bit longer, but I think you will ultimately get the care you need.
You have to reference it to the system we have now.
What about the enormous number of people across the country that cannot get care?
It’s not about wait times.
They’re dying.
They’re dying.

So, what you’re saying is to cover everybody, if some people have to wait a little bit longer, it’s gonna be worth it?
That’s the cost you have to pay as a society.

If it’s even true, but, sure.

How realistic, how achievable, do you believe your version of Medicare for All is?

It is so achievable.

How politically possible is it?

Oh, look, politics is the art of the possible, and our job is to push the boundaries of what’s possible.
When people said, ‘Let’s go to the Moon,’ people said it wasn’t possible.
When people said, ‘Let’s give women the right to vote,’ people said it wasn’t possible.
If we listen to people who say things weren’t possible, we would never be the country we are.
It requires some courage to take on the system that is profiting a very few today and leaving so many Americans without this critical healthcare that they deserve.
It’s a right.
Let’s give healthcare to everybody.

Pramila Jayapal, thank you for coming to ‘Firing Line.’

Thank you.
Great to talk to you.

Appreciate it.

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